The Deadly Consequences of
Being Uninsured
Families USA
Dying for Coverage:
The Deadly Consequences of Being Uninsured
© June 2012 by Families USA
This publication is available online at www.familiesusa.org.
Families USA
1201 New York Avenue NW, Suite 1100
Washington, DC 20005
Phone: 202-628-3030
Fax: 202-347-2417
Email: info@familiesusa.org
Cover Design: Nancy Magill, Families USA
Dying for Coverage
T
he number of uninsured Americans reached an all-time
high in 2010, as nearly 50 million Americans went without
health insurance for the entire year.1 For many of these
uninsured people, the consequences of going without
coverage are dire. The uninsured frequently face medical debt or go
without necessary care, and too many of them die prematurely.
In 2002, the Institute of Medicine released a groundbreaking report, Care without
Coverage: Too Little, Too Late. This report estimated that, nationwide, 18,000
adults between the ages of 25 and 64 died in 2000 because they did not have
health insurance.2 Since then, the crisis of the uninsured has grown even larger.
During the economic downturn, millions of Americans lost both their jobs and
their health coverage, and rising health insurance premiums have priced many
more out of coverage.
Thankfully, the new health care law can help stem the rising tide of the
uninsured. Beginning in 2014, millions of Americans will be eligible for assistance
with the cost of health coverage. In addition, insurance companies will no longer
be able to deny coverage or charge higher premiums to people with pre-existing
conditions. These measures, among others, will help reverse the growth in the
number of uninsured Americans year after year.
The fate of the health care law, however, is now in question. The Supreme Court
is currently reviewing the constitutionality of the law, and well-funded rightwing activists are intent upon securing its demise. If the law is struck down, the
effects would be catastrophic. Without the law, the number of uninsured will
continue to rise, and more Americans will face the adverse health and financial
consequences associated with going uninsured. Millions will delay or forgo
necessary care. Millions more will face unmanageable medical bills. And, worse
still, many will die prematurely.
To estimate the number of Americans who are dying for lack of health coverage,
Families USA applied the methodology developed by the Institute of Medicine to
state-level population and mortality data. This is one measure of the great need
for the Affordable Care Act. As our analysis shows, far too many Americans are,
quite literally, dying for coverage.
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Dying for Coverage
Key Findings
„„ Across the nation, 26,100 people between the ages of 25 and 64 died prematurely due
to a lack of health coverage in 2010 (Table 1). That works out to:
„„
2,175 people who died prematurely every month;
„„
502 people who died prematurely every week;
„„
72 people who died prematurely every day; or
„„
Three every hour.
„„ Between 2005 and 2010, the number of people who died prematurely each year due
to a lack of health coverage rose from 20,350 to 26,100 (Table 1).
„„ Between 2005 and 2010, the total number of people who died prematurely due to a
lack of health coverage was 134,120 (Table 2).
„„ Each and every state sees residents die prematurely due to a lack of health insurance.
In 2010, the number of premature deaths due to a lack of health coverage ranged
from 28 in Vermont to 3,164 in California (Table 3).
„„ The five states with the most premature deaths due to uninsurance in 2010 were
California (3,164 deaths), Texas (2,955 deaths), Florida (2,272 deaths), New York (1,247
deaths), and Georgia (1,161 deaths) (Table 3).
Table 1.
Deaths Due to a Lack of Health Coverage, 25- to 64-Year-Olds,
2005-2010
Year
Deaths
Per Hour
Deaths
Per Day
Deaths
Deaths Total Deaths Due
Per Week Per Month To Uninsurance
2005 2.3 56 3911,696
20,350
2006 2.4 58 4061,761
21,130
2007 2.4 57 3971,721
20,660
2008 2.5 60 4181,812
21,750
2009 2.8 66 4642,011
24,130
2010 3.0 72 5022,175
26,100
Source: Families USA calculations based on estimates by the Institute of Medicine.
Dying for Coverage
Table 2.
Deaths Due to a Lack of Health Coverage, 25- to 64-Year-Olds, by State,
2005-2010
State
Total Deaths,
2005-2010
State
Total Deaths,
2005-2010
Alabama2,668
Montana483
Alaska344
Nebraska480
Arizona3,417
Nevada1,504
Arkansas1,998
New Hampshire
California16,285
New Jersey
2,980
Colorado1,652
New Mexico
1,404
Connecticut825
New York
6,481
Delaware314
North Carolina
4,843
DC290
North Dakota
Florida12,336
Ohio4,496
Georgia5,624
Oklahoma2,424
Hawaii289
Oregon1,687
Idaho551
Pennsylvania3,778
Illinois4,946
Rhode Island
Indiana2,458
South Carolina
Iowa777
South Dakota
Kansas875
Tennessee3,483
Kentucky2,298
Texas15,435
Louisiana3,346
Utah687
Maine398
Vermont154
Maryland2,075
Virginia2,706
Massachusetts
*
Michigan3,584
Washington2,069
Minnesota846
Wisconsin1,204
Mississippi2,289
Wyoming248
Missouri2,515
U.S. Total
339
179
276
2,927
240
West Virginia
1,223
134,120
Source: Families USA calculations based on estimates by the Institute of Medicine.
* Massachusetts data are not reportable because they do not reflect the state’s health reform
program.
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Dying for Coverage
Table 3.
Deaths Due to a Lack of Health Coverage, 25- to 64-Year-Olds,
By State, 2010
State
Deaths Per Week
Deaths Per Month
Total Deaths,
2010
Alabama 1043
Alaska
15
512
59
Arizona 1252
621
Arkansas 833
394
California 61264 3,164
Colorado 523
280
Connecticut3 15
178
Delaware15
56
District of Columbia
51
Florida
1
4
44189 2,272
Georgia 2297 1,161
Hawaii 14
Idaho
Illinois
211
50
129
1984 1,012
Indiana 1042
499
Iowa
315
177
Kansas
314
171
Kentucky 836
436
Louisiana 1357
679
Maine
16
Maryland 833
67
398
Massachusetts
**
*
Michigan1564 763
Minnesota 416
193
Mississippi 939
470
Missouri
461
938
Montana 28
99
Nebraska2 8
92
Dying for Coverage
Table 3 cont’d.
Deaths Due to a Lack of Health Coverage, 25- to 64-Year-Olds,
By State, 2010
State
Deaths Per Week
Deaths Per Month
Total Deaths,
2010
Nevada
627
New Hampshire
1
5
61
New Jersey
11
49
583
New Mexico
5
21
251
New York
24
104
1,247
North Carolina
18
78
931
North Dakota
1
3
36
Ohio
320
1776
907
Oklahoma 938
452
Oregon
293
624
Pennsylvania14
Rhode Island
62
745
1
5
56
South Carolina
12
52
625
South Dakota
1
4
46
Tennessee12 53
Texas
Utah
Vermont
633
57246 2,955
211
126
**2
28
Virginia 1148
574
Washington8 35
419
West Virginia
223
4
19
Wisconsin 522
270
Wyoming14
51
U.S. Total
502
2,175
26,100 ***
Source: Families USA calculations based on estimates by the Institute of Medicine.
*Massachusetts data are not reportable because they do not reflect the state’s health
reform program.
**One Vermonter dies every two weeks due to lack of health coverage.
*** Total does not add due to rounding.
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Dying for Coverage
Why Insurance Matters
The uninsured are less likely to have a usual source of
care outside of the emergency room.
„„
Uninsured adults are five times less likely to have a regular source of
care than the insured (55 percent versus 11 percent).3
„„
More than half (51 percent) of the uninsured adults who tried to find
a new primary care doctor in the past three years reported that it was
“somewhat difficult” or “very difficult,” with one in five (20 percent)
responding that it was “very difficult.” 4
„„
More than two in five uninsured adults (41 percent) reported that a
doctor’s office or clinic from which they sought primary care would
not accept them as a new patient.5
The uninsured often go without screenings and
preventive care.
„„
Uninsured adults are nearly four times more likely than insured adults
to delay or forgo getting a preventive care screening due to cost (36
percent versus 10 percent).6
„„
Uninsured women over the age of 50 were about half as likely to have
gotten a mammogram in the past two years as insured women (42
percent versus 79 percent).7
„„
Lower-income uninsured people (those with incomes below 250
percent of the federal poverty level) aged 50 to 64 were five times
less likely (10 percent versus 50 percent) than insured people in the
same age group to have gotten a colon cancer screening in the past
five years.8
Dying for Coverage
The uninsured often delay or forgo needed medical care.
„„
Uninsured adults are more than six times as likely as privately insured
adults to go without needed care due to cost (26 percent versus 4
percent).9
„„
Cancer patients without health insurance are more than five times
more likely to delay or forgo cancer-related care because of medical
costs than insured patients (27 percent versus 5 percent).10
Uninsured Americans are sicker and die earlier than those
who have insurance.
„„
Uninsured adults are more likely to be diagnosed with a disease in
an advanced stage. For example, uninsured women are substantially
more likely to be diagnosed with advanced stage breast cancer
than women with private insurance,11 as are uninsured people with
colorectal cancer.12
„„
Uninsured adults are at least 25 percent more likely to die
prematurely than adults with private health insurance.13
The uninsured pay more for medical care.
„„
Uninsured patients are unable to negotiate the discounts on hospital
and doctor charges that insurance companies do. As a result,
uninsured patients are often charged more than 2.5 times what
insured patients are charged for hospital services.14
„„
Three out of five uninsured adults (60 percent) under the age of 65
report having problems with medical bills or medical debt.15
7
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Dying for Coverage
Endnotes
1
Carmen DeNavas-Walt, Bernadette D. Proctor, and Jessica C. Smith, Income, Poverty, and Health Insurance Coverage in the
United States: 2010 (Washington: U.S. Census Bureau, September 2011).
2
Institute of Medicine, Care without Coverage: Too Little, Too Late (Washington: National Academy Press, 2002).
Kaiser Family Foundation, The Uninsured: A Primer, Key Facts about Americans without Health Insurance (Washington: Kaiser
Family Foundation, October 2011).
3
Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty, The Income Divide in Health Care: How the Affordable Care
Act Will Help Restore Fairness to the U.S. Health System (New York: The Commonwealth Fund, February 2012).
4
5
Ibid.
Sara R. Collins, Michelle M. Doty, Ruth Robertson, and Tracy Garber, Help on the Horizon: How the Recession Has Left Millions
of Workers without Health Insurance, and How Health Reform Will Bring Relief (New York: The Commonwealth Fund, March
2011).
6
7
Ibid.
8
Sara R. Collins, Ruth Robertson, Tracy Garber, and Michelle M. Doty, op. cit.
9
Kaiser Family Foundation, op. cit.
The USA Today/Kaiser Family Foundation and Harvard School of Public Health, National Survey of Households Affected by
Cancer (Washington: Kaiser Family Foundation, 2006).
10
Daniel T. Farkas, Arieh Greenbaum, Vinay Singhal, and John M. Cosgrove, “Effect of Insurance Status on the Stage of
Breast and Colorectal Cancers in a Safety-Net Hospital,” The American Journal of Managed Care 18, Special Issue no. 2 (May
2012): SP65-SP70; Michael Halpern, John Bian, Elizabeth Ward, Nicole Schrag, and Amy Chen, “Insurance Status and Stage
of Cancer at Diagnosis among Women with Breast Cancer,” Cancer 110, no. 2 (June 11, 2007): 403-411; Cathy J. Bradley,
David Neumark, Lisa M. Shickle, and Nicholas Farrell, “Differences in Breast Cancer Diagnosis and Treatment: Experiences of
Insured and Uninsured Women in a Safety Net Setting,” Inquiry 45, no. 3 (Fall 2008): 323-339.
11
12
Daniel T. Farkas, Arieh Greenbaum, Vinay Singhal, and John M. Cosgrove, op. cit.
Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care (Washington: National Academy
Press, 2009); Institute of Medicine, Insuring America’s Health (Washington: National Academy Press, 2002).
13
Gerard Anderson, “From ‘Soak the Rich’ to ‘Soak the Poor’: Recent Trends in Hospital Pricing,” Health Affairs 26, no. 3
(May/June 2007): 780-789.
14
15
Sara R. Collins, Michelle M. Doty, Ruth Robertson, and Tracy Garber, op. cit.
Dying for Coverage
Methodology
To estimate the number of lives that are lost due to uninsurance among the working-age
population in the United States, Families USA applied the methodology developed by
the Institute of Medicine (IOM) in 2002 to current data.1 This methodology was based on
research that found that, after controlling for numerous factors, the absence of insurance
coverage increases mortality by an average of 25 percent for adults aged 25-64.2 In 2009,
IOM issued a follow-up report that concluded that more recent research confirmed the
earlier findings about the effect of insurance on mortality, explaining that “the body of
evidence on the effects of uninsurance on adults’ health has strengthened considerably
since 2002.” 3
The original IOM report estimated mortality effects algebraically, solving for UD, the
number of individuals who would have died if the entire population had health coverage.
Its analysis began with the obvious fact that the total number of deaths in a population
is the sum of deaths among the insured and deaths among the uninsured. The number of
deaths among the insured can be represented as the product of (a) the percentage of the
population with health coverage and (b) the number who would die if everyone had health
coverage. The number of deaths among the uninsured is likewise the product of (a) the
percentage of the population without health coverage and (b) the number of total deaths
if everyone had health coverage, increased by 25 percent, based on the above-described
finding that uninsurance increases mortality by 25 percent. Expressed algebraically:
let PI = the percentage of the population with insurance;
let PU = the percentage of the population without insurance;
let AD = the number of actual deaths; and
let UD = the number of deaths that would result if coverage were universal.
Accordingly:
AD = (UD * PI) + (UD * 1.25 * PU) = UD * (PI + (1.25 * PU))
As a result:
UD = AD / (PI + (1.25 * PU))
and the number of lives lost because of uninsurance is:
AD – UD.
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Dying for Coverage
Applying the IOM methodology to estimate the annual mortality effects of uninsurance
within a given population of adults aged 25 through 64 thus requires the following three
data points:
„„
The size of the population;
„„
The population’s mortality rate, which, together with total population size, allows
a calculation of the number of deaths; and
„„
The percentage of the population that is uninsured.
Like the IOM, Families USA applied this analysis to uninsured adults in four age groups:
25-34, 35-44, 45-54, and 55-64, using data for 2005 through 2010. The resulting mortality
estimates were summed to show the overall number of deaths attributable to an absence
of insurance coverage among adults aged 25-64.
For 2005 through 2010, Families USA determined the total number of adults within each
10-year age band and the percentage who lacked health coverage based on the U.S.
Census Bureau’s Current Population Survey (CPS) data. To calculate the number of deaths
for a given year, we applied to each 10-year cohort the age-specific, state-specific annual
mortality rate reported by the Centers for Disease Control and Prevention’s National
Center for Health Statistics. We used final mortality rate estimates through 2009. For
2010, we projected a mortality rate for each age group based on the average mortality
rate among each age group for 2005 through 2009. We applied these same state-specific
mortality rates to state estimates of population size and insurance status from the CPS.
For several reasons, this methodology underestimates the mortality effects of uninsurance:
„„
Our mortality estimates ignore the benefits of health insurance for individuals
under 25 years of age. Even for children, recent research has shown that the
absence of insurance increases mortality.4
„„
Like the IOM, we calculated the mortality effects of uninsurance within 10-year
age bands rather than for all adults aged 25-64. This lowered our mortality
estimates by more than 15 percent, according to the findings of observers who
conclude that the alternative, higher mortality estimates are sounder, since the
studies on which the IOM relied analyzed the effect of insurance on the entire
population of adults aged 25-64, rather than on each 10-year cohort.5
Dying for Coverage
„„
The IOM’s finding that the absence of insurance raises mortality rates by
25 percent fails to account for the increasing effectiveness of health care in
preserving health and saving lives. A study published by Harvard Medical School
researchers late in 2009 that used more recent data found that the lack of
health insurance now raises mortality rates by 40 percent.6 If we had applied
the latter estimate of the impact of uninsurance on mortality, rather than the 25
percent figure used by the IOM, our mortality estimates would have increased
substantially.
In short, our numbers are best viewed as conservative estimates of the general magnitude
of lives lost because of uninsurance, rather than a precise and certain “body count.”
1
Institute of Medicine, Care without Coverage: Too Little, Too Late (Washington: IOM, May 2002).
P. C. Franks, M. Clancy, and M. R. Gold, “Health Insurance and Mortality: Evidence from a National Cohort,” Journal of
the American Medical Association 270, no. 6 (1993): 737–41; P. D. Sorlie, N. H. Johnson, E. Backlund, and D. D. Bradham,
“Mortality in the Uninsured Compared with That in Persons with Public and Private Health Insurance,” Archives of Internal
Medicine 154, no. 21 (November 1994): 2,409–2,416.
2
Institute of Medicine, America’s Uninsured Crisis: Consequences for Health and Health Care (Washington: IOM, February 23,
2009), p. 70.
3
4
One recent study found, after controlling for multiple factors, that in-hospital mortality rates were 60 percent higher for
uninsured than insured children. Out of an estimated 38,649 hospital deaths among uninsured children over an 18-year
period, 16,787 deaths, or 37.8 percent, may have been prevented by health insurance. Fizan Abdullah, Yiyi Zhang, Thomas
Lardaro, Marissa Black, Paul M. Colombani, Kristin Chrouser, Peter J. Pronovost, and David C. Chang, “Analysis of 23 Million
U.S. Hospitalizations: Uninsured Children Have Higher All-Cause In-Hospital Mortality,” Journal of Public Health 32, no. 2
(June 2010): 236-244, first published online on October 29, 2009; pp. 1–9.
5
Stan Dorn, Uninsured and Dying Because of It: Updating the Institute of Medicine Analysis on the Impact of Uninsurance on
Mortality (Washington: Urban Institute, January 2008), prepared by the Urban Institute for the Robert Wood Johnson
Foundation.
6
Andrew P. Wilper, Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein,
“Health Insurance and Mortality in U.S. Adults,” American Journal of Public Health 99, no. 12 (December 2009): 2,289-2,295.
11
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Dying for Coverage
Acknowledgments
This report was written by:
Kim Bailey
Research Director
Families USA
The following Families USA staff contributed
to the preparation of this report:
Kathlen Stoll, Deputy Executive Director,
Director of Health Policy
Peggy Denker, Director of Publications
Ingrid VanTuinen, Deputy Director of Publications
Nancy Magill, Senior Graphic Designer
Dying for Coverage
Recent Families USA Publications
Decoding Your Health Insurance: The New Summary of Benefits and Coverage
National and state-level data on the nearly 173.5 million people with private insurance
who will be helped by these plain-language summaries that are required by the health
care law. (May 2012)
Good Business Sense: The Small Business Health Care Tax Credit in the Affordable Care Act
National and state-level estimates of how many small businesses will be eligible and how
much the credits will be worth. Also includes data on how many workers could benefit.
(Done in conjunction with Small Business Majority, May 2012)
Alcohol Taxes and Public Health
The health benefits of higher alcohol taxes, which can also be an important source of
funding at the local, state, and federal levels. (May 2012)
A Nation in Need of Dental Care
The effects of limited access to dental care on overall health, productivity, and financial
security. (May 2012)
What’s Wrong with Premium Support in Medicare?
A look at the Republican proposal that would end Medicare as we know it and turn it into
a voucher program. (April 2012)
Republicans Again Propose Slashing Funding for Medicaid, Medicare, and Other Health
Programs
How the Republican budget proposal would affect the states. Includes state-level data on
the federal funding each state would lose, the additional burden on taxpayers, and the
rise in the number of uninsured residents. (April 2012)
A complete list of Families USA publications is available online at
www.familiesusa.org/resources/publications/.
13
1201 New York Avenue NW, Suite 1100 • Washington, DC 20005
Phone: 202-628-3030 • Fax: 202-347-2417 • Email: info@familiesusa.org
www.familiesusa.org